Trichotillomania: Its Classification and Treatment

Adams, Kim, Jones, John V., Jr., TCA Journal

Trichotillomania is categorized as an Impulse-Control Disorder. The following article brings to light that this disorder man not be as rare as some clinicians think. The following discussion delineates Trichotillomania in terms of its descriptive characteristics, onset and course, associated disorders, relationship to Obsessive-Compulsive Disorder, and treatment. Research indicates a combination of psychopharmacology and cognitive-behavioral therapy as the choice of treatment for this disorder. Following the content discussion of Trichotillomania is a transcript of an interview with one of the authors (K. A.) who was previously diagnosed with Trichotillomania.

INTRODUCTION

Trichotillomania is categorized as an Impulse-Control Disorder and is defined by the following five criteria listed in the DSM-IV (1994):

a) recurrent pulling of one's hair resulting in noticeable hair loss, b) an increasing sense of tension immediately before pulling out the hair or when attempting to resist the behavior, c) pleasure, gratification, or relief when pulling out the hair, d) the disturbance is not better accounted for by another mental disorder and is not due to a general medical condition, e) the disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning. (p. 621) This article seeks to provide an overview of Trichotillomania in terms of its history and descriptive characteristics, onset and course of illness, associated disorders, its relationship to Obsessive-Compulsive Disorder, and the treatment of choice for Trichotillomania.

HISTORY AND DESCRIPTIVE CHARACTERISTICS

History

In 1889 a French dermatologist, Hallopeau, described a man who pulled out his hair in large amounts (Swedo, 1993). Hallopeau used the term "trichotillomania" to describe this behavior. Before Hallopeau's encounter with his client, references to hair-pulling had already been documented. In 1779, Baudament reported on a 16-year-old boy who pulled out his hair and actually ate it. Eventually, this ingestion of hair led to gastrointestinal problems because the boy developed hair balls in his stomach (Christenson & Mackenzie, 1994).

Once thought to be rare, this disorder is far from uncommon. It has been estimated that approximately eight million Americans are afflicted with this disorder (Azrin & Nunn, 1978). A survey conducted by Rothbaum, Shaw, Morris, and Ninan (1993) revealed that of the 490 college freshman respondents, 10% reported compulsive hair-pulling. Despite these statistics, the literature is very scarce regarding this disorder.

Characteristics

Trichotillomania is predominately found in the female population. Christenson, Mackenzie, and Mitchell (1991) found that 93% of 60 adult chronic hair-pullers were women. Likewise, Swedo and Leonard (1992) found that 70% of 43 sampled children, adolescents, and adults who were chronic hair-pullers were female. Christenson and Mackenzie (1994) found a more equal sex ratio in children under the age of six.

Hair-pulling can occur from many different body locations. A study done by Swedo and Leonard (1992) found that the most common area from which hair is pulled is the scalp, followed by eyelashes, eyebrows, pubis, body (arm/leg), and face (beard). Most individuals pluck hair from at least two sites, with sites varying over time. Those diagnosed with this disorder typically think that the hair that is pulled is somehow "different" from other hair. For example, chronic hair-pullers may pluck kinky or course hair so that they may "feel right" about their hair, thus reducing anxiety (Swedo & Rapoport, 1991.).

After the hair is pulled, other ritualistic acts can follow. For instance, some individuals will play with or twirl their extracted hair, while others may brush it against their cheeks or lips. Some individuals will even go as far as ingesting their hair (trichophagia), possibly leading to gastrointestinal difficulties or even death (Swedo & Leonard, 1992). …

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